Using basic technology to screen for diabetic retinopathy in Fiji.

The World Health Organization (WHO) estimates that almost 12 per cent of Fijians have diabetes. Although there are no official figures on the prevalence of diabetic retinopathy, a complication of diabetes, it is the second most common cause of vision loss after cataract in our hospital in Labasa, Fiji. 
 
One of the main problems with treating diabetic retinopathy is that patients remain asymptomatic until their disease is very advanced. They then present for evaluation when it may be too late to preserve their vision. 
 
Ideally, we would like to identify people with diabetic retinopathy as early as possible so treatment can begin when it is more effective. However, screening large numbers of diabetic patients in clinics is difficult both because of the distances patients have to travel and because of limited health care resources (including human resources). In addition, people with diabetes are reluctant to make use of the health care system until their disease is very advanced. This is true both in Fiji and in developing countries around the world. 
 
In order to provide a solution to this problem, we devised a simple photographic system to screen for diabetic retinopathy using a portable camera. This system could be implemented in conditions where there were no personnel experienced in fundus photography and where there was no financial support or information technology infrastructure. We decided to test this screening system in the field. 
 
We chose a Topcon NW100 non-mydriatic camera (see picture above), because it was durable and easy to use (indeed, after practising with this camera for about an hour, a motivated student will be able to take acceptable fundus photographs). Although the camera can be used without mydriatics, it is much easier to photograph the retina if the pupils are dilated with 0.5 per cent (or 1 per cent) tropicamide, especially if there are no darkened rooms in which to take the photographs. One of the nurses at our hospital in Labasa was trained in the use of the camera; she had no previous experience with either ophthalmic photography or fundus examination. 
 
 
 
 
 
Clinically significant macular oedema with hard exudates encroaching on the fovea, identified using photographic screening in an asymptomatic patient. 
 
 
 
 
 
 
 
 
 
The camera being used in an outlying medical clinic. FIJI 
 
 
 
This nurse travelled with the camera to small outlying medical clinics. There, she performed a preliminary examination with a torch to eliminate patients with obvious anterior segment problems, such as dense cataract, that would preclude photography. A total of 115 patients were photographed during this first screening mission. The images were stored on a laptop computer. An ophthalmologist at our hospital later analysed these images and provided a photographic diagnosis for each image. 
 
In total, 75 per cent of the images (86 patients) were readable, meaning they were of sufficient quality to determine whether further evaluation was warranted. Nine patients showed signs of diabetic retinopathy which would require laser treatment. These patients were then contacted by the outlying clinics and arrangements were made to bring them to our hospital for evaluation. All of these patients came in for treatment and in all cases the photographic diagnosis was correct. In the remaining 25 per cent of cases, the images weren't readable; these patients were also encouraged to come to our hospital for a further examination. 
 
We have since organised six further screenings. Of the 370 patients examined, a total of 30 per cent were found to have some degree of diabetic retinopathy and 8–9 per cent had retinopathy that was severe enough to require laser treatment. So far, all patients requiring laser have attended our hospital for treatment. The quality of the photographs has also improved with experience; far fewer pictures are now unreadable. 
 
With this photographic screening technique, it is also possible to identify patients with milder degrees of retinopathy, who do not yet require treatment. This pool of patients is perhaps the most important, because they (and their physicians) can be made aware of any changes in their diabetes and of the need for improved control and monitoring of the disease. 
 
Perhaps the most precarious aspect of this project is that everything depends on the ruggedness of the camera; we are very careful with maintaining and transporting it (no patients can be seen if the camera breaks). For instance, on the first day, the camera had been stored in an air-conditioned room; when it was taken outside it became soaked with condensation inside and out. Fortunately, it worked perfectly once it had dried out. 
 
This screening method allows physicians' time to be used more efficiently, as they don't have to examine diabetic patients without retinopathy and can focus their attention on those needing treatment. This approach also has the advantage of identifying disease at an earlier stage, when treatment is both more effective and less time consuming.

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Supporting VISION 2020: The Right to Sight
The journal is produced in collaboration with the World Health Organization

Community Eye Health
Journal Impact of ageing on eye care systems For many low-income countries, such an increase in the number of older people will be particularly challenging as this change in the population may take place before there has been sufficient economic development to deal with its effects. In particular, an ageing population will place an extra burden on the health care system in general.
The prevalence of visual impairment increases with age. Although people aged 50 years and above only represent 19 per cent of the world's population, more than 82 per cent of people living with blindness are in this age group. 2 A rise in the number of older people in a population will therefore be accompanied by an increase in the number of people with age-related eye diseases, such as cataract and age-related macular degeneration.
The costs associated with treatment and rehabilitation can be expected to increase dramatically over the next few decades.
In lower-income countries, different generations tend to live under one roof and the role of caring for older people falls mainly to the family. Relatives also have to meet the costs associated with treatment and rehabilitation.
In many middle-and high-income countries, however, older people are becoming increasingly isolated. This is due to the breakdown of the family unit and the need for working-age relatives to move in order to find employment. As people age alone, without family members to look after them, governments might face increased pressure to provide care; this could include meeting the costs of treatment and rehabilitation.

Impact on society
Not all the costs associated with an increase in age-related diseases are financial. Visual impairment has a negative impact on the lives of older people, their families, and society as a whole.
Older people with good vision can, and do, remain economically and socially active as they age, and they contribute significantly to the wellbeing of their families and to society in general (see article on page 24). This contribution is particularly important in populations affected by HIV and AIDS, where children may have lost both their parents and are looked after by grandparents. Unfortunately, visual impairment dramatically reduces the ability of older people to contribute to their full capacity, which has a negative impact on society as a whole.
What can be done about the impact of ageing on eye health?
Considerable resources are needed to help older people overcome the limitations imposed by poor vision.

Improving access to treatment
Despite the fact that much visual impairment in older people is due to correctable conditions such as refractive error and cataract, older people in many countries still suffer from these conditions. Even in high-income countries such as the UK, where good quality eye care is free at the point of delivery, there are high levels of visual impairment in older people. 3 This problem is particularly acute among older people who do not live in the community, for example, people living in residential homes or nursing homes.
Older people face particular challenges when accessing health care, including eye care. One of the reasons is that, as people age, many health problems can occur at the same time. In the presence of multiple health problems, vision problems probably assume a lesser importance; in addition, these other health problems can make it physically more difficult for an older person to access eye care. Expectations and activities also decrease with age, which affects older people's desire to seek help with their health problems, including eye problems.
The article on page 26 discusses these and other challenges older people face when trying to access eye care and offers some suggestions for overcoming them.

Prevention
Although safe and effective treatment for cataract is available, the costs to society of dealing with this problem on such a wide scale may become very high. In addition, the new treatments emerging for age-related macular degeneration are currently too costly to benefit more than a small portion of those suffering from this condition.
Prevention of cataract and age-related macular degeneration may therefore become particularly important in the future. Although we hope to uncover more evidence about the prevention of these conditions, there already exists very clear evidence that tobacco smoking is a risk factor for both conditions.
Almost one billion men in the world smoke, but levels of smoking in men appear to be declining. 4 Although the rates of smoking in women are declining in high-income countries, this is by no means the case worldwide. Overall, healthier, better educated people are heeding public health warnings Most high-income countries use the chronological age of 65 years to define older people. For Africa, the current recommended cutoff is 50 years. Although the United Nations currently have no standard numerical criterion, the generally accepted cutoff is 60 years and above. (www.who.int) When is someone an older person?
Populations are ageing because of increased life expectancy and decreased birth rates. The theme of World Sight Day 2008 is the ageing eye and visual impairment in older people. The headline "Eyes on the Future" recognises that, in a world where populations are ageing and individuals are living longer, blindness from chronic conditions is also on the increase.
World Sight Day is the annual day of awareness for blindness and visual impairment and is held on the second Thursday of October (this year it is on 9 October 2008). Included on the offi cial calendar of the World Health Organization, it is coordinated by IAPB under the VISION 2020 Global Initiative. The global theme and certain promotional materials are generated by IAPB.
All World Sight Day events are organised independently by members and supporters of VISION 2020. IAPB encourages all organisations concerned with eye health to arrange events and displays to mark this special day. Ideas for events include competitions, eye screening camps, sponsored walks, and gala dinners. Promotional posters, bookmarks, and offi cial literature can be requested from IAPB. See www.v2020. org/wsd08 for more details.

Photo courtesy of Brendan Esposito/Fairfaxphotos and The Fred Hollows Foundation
Photoi Zul Mukhida/Sightsavers on the dangers of smoking. However, smoking is now becoming much more concentrated in poorer, less educated populations; this is precisely the group which has been shown to be in worse health and to have more limited access to health care. Therefore, there should be a focus on public health interventions in poorer, less educated populations to reduce levels of smoking.
The relationship between nutrition during life and age-related eye diseases is currently being investigated. Firm public health recommendations on this issue cannot be made at present. It is more than likely, however, that a healthy and active old age requires adequate levels of nutrition at all stages in life.
Maintaining good vision is an important part of 'active ageing', a concept promoted by the World Health Organization. Active ageing means: continued health, security, and participation in society as people age, in order to ensure a good quality of life in later years. 5 As eye care practitioners, therefore, we should work together with other health and social services to help those in our care remain as active as possible in their later years.

Changing attitudes to ageing
Changes in attitudes towards ageing and older people, which differ in different parts of the world, will no doubt infl uence the consequences of ageing in different regions.
On the one hand, societies traditionally respectful towards older people are fi nding that the gradual globalisation of culture can lead to a 'culture of youth'. This can mean that youth is idealised and that there is less respect towards older people.
On the other hand, because the number of older people is increasing as a proportion of the total population, their voices may have a better chance of being heard. This is particularly true in high-income countries, where this new phenomenon has been called 'grey power' or 'grey dollar' to indicate that the commerce and industry sector is beginning to appreciate the economic power of these older consumers. This societal change is reinforced by the fact that, in these countries, the new generations of older people are used to being vocal and politically active. This may result in increased respect for, and responsiveness to, the needs of older people.
With increasing health awareness in all countries, we may also hope for a 'generational effect': it is possible that current generations, more used to being 'consumers' of health care, will engage actively with health care services in their later years. Rapid changes in access to information, thanks to the internet and other digital media, will undoubtedly have an effect as users of health care services will become more informed about what is available to them.

Conclusion
For any country, an ageing population is something to be proud of; it is a success story refl ecting the fact that people are living longer and healthier lives. However, it is important to plan for the effects of an ageing population, both in terms of health care provision and public health campaigns. Appropriate public health messages should be provided at all ages to encourage healthy lifestyles that promote eye health in the long term. We must also ensure that older people have good access to eye care services. 'An ageing population is something to be proud of'